Bulimia Nervosa

Bulimia nervosa (Greek: "nervous ox hunger"), "an irresistible urge to
overeat, followed by self-induced vomiting or purging", was first
described in the medical literature in 1979. However, overeating is
mentioned in Greek mythology, and purging has often been associated
with overeating. Traditionally bulimic patients purge by vomiting,
but the availability of laxatives -- and even diuretics -- give
these patients more options. Purging, and the side effects of purging,
are responsible for many of the medical problems that bulimic patients
develop.

We define this as eating, in any time period, more food than
most other people would eat in the same time period and under the
same circumstances. A binge meal may contain 10,000 calories, or
more, but may also involve no more food than a normal meal. (A
football player eats very large meals during training and on game
days, but the nutrition in those meals more or less matches the
energy he expends).

Loss of control over eating during the binge

The difference between ordinary eating and bingeing is that the
bingeing patient feels like she has lost control of her eating
(what she is eating, how much she is eating, and not being able
to stop herself from eating once she has had enough).

Inappropriate ways of making up for the binges

The classic "purging-type" bulimic patient tries to get rid of the
binged food after she eats it. Purging is often done with emetics
such as ipecac, but many patients learn to make themselves
vomit with their fingers or with objects like toothbrush handles.
Some patients use laxatives or enemas to increase stool output,
hoping that this will reduce their weight and decrease absorption
of calories. Other bulimic patients take diuretics to lose weight;
this gets rid of water but doesn't really affect body weight
otherwise. Bulimic (and anorexic) diabetics have been known to
stop their own insulin: this causes their blood sugar to go way
up, which also leads to increased urination (among a lot of other
bad effects). Some bulimic and anorexic patients have used
stimulants (such as the medications for ADHD) or thyroid hormone
to make themselves lose weight.

Less commonly, we see non-purging bulimic patients. These patients
also binge but fast between binges or exercise excessively.

In early bulimia, a patient often feels that she now has control over her
weight, and has the satisfaction of being able to eat large amounts of
food without gaining weight. As the disease progresses, though, her
feelings of control and satisfaction wear off. Hunger after purging leads
to “compensatory” bingeing, and a vicious cycle develops, made worse by
other provocations to binge including anxiety, depressed mood, and boredom.
Substances that make her feel less inhibited, such as alcohol, also make
things worse, and certain “forbidden” foods can also trigger binges.
Patients tend to binge while they are alone, and they may hoard food so
they can binge in privacy later. Like anorexic patients, bulimic patients
will go to great lengths to hide their disordered eating from family and
friends.

Bulimia usually starts in early adulthood or the late teens, unlike anorexia
which tends to start around puberty. Bulimia often starts during or after
a period of dieting, when a patient figures out that she can cut the
calories her body keeps in by purging after eating. However, many patients
begin bingeing before changing their diets. Like patients with
anorexia,
patients with bulimia are much more worried about their appearance and
weight than they should be. In fact, almost one-third of bulimic patients
were previously anorexic. Also like anorexia, bulimia sometimes runs in
families. However, unlike most anorexic patients, bulimic patients often
were obese as children or had obese parents, and are more likely to have
been criticised for being overweight or for their eating habits than
are anorexic patients. Anxiety and mood problems are also common in bulimic
patients than in other groups; as one example, up to 3/4 of bulimic patients
also have or have had an affective disorder such as depression. Substance
abuse is also seen more often in bulimic patients than in other groups.
Past abuse, especially sexual abuse, in childhood is associated with later
development of eating disorders, particularly bulimia; and bulimic patients
also seem more likely than others to be novelty-seeking and impulsive.

Most bulimic patients are either overweight or of normal weight. This can
actually be dangerous: anorexic patients usually look like they are
starving but bulimics may appear relatively normal even though they are
really quite ill.
The most dangerous problem in bulimia is imbalance of important minerals,
especially potassium. The electrical cells in your body (your nerve cells
and your muscles) depend on tightly-controlled levels of potassium in your
blood. Both vomiting and most diuretics make your body get rid of
potassium, and some laxatives can mess up your mineral balance as well.
If your blood potassium level is either too high or too low, those
cells do not work properly, and the consequences can range from seizures
to a stopped heart. (This has happened in some very (in)famous cases.)
Purging can also upset acid-base balance in the body, making body fluids
either too acid or not acid enough, and can also affect the heart's
electrical systems in other ways,

Other major potential problems can result from retching and vomiting.
These range from bleeding from, to rupture of, the stomach or esophagus
due to tissue being torn while retching and vomiting. A patient can also
bleed from the back of the mouth and throat after lacerations from whatever
she sticks down there to make herself vomit. As with any vomiting, it is
possible for someone to aspirate the vomited material into the
windpipe and lungs; this can kill you, too.

Another serious problem is seen in bulimics who use ipecac to make
themselves vomit. When taken repeatedly for a long time, ipecac can cause
myopathy (muscle malfunction) in both skeletal muscles (like those
in the arms and legs) and in the heart muscle. This usually doesn't
happen until someone takes a lot of ipecac over weeks to months, but some
bulimic patients do just that: I have taken care of patients with
impending heart failure who got there because they had been abusing
ipecac for months. Patients with ipecac myopathy usually get better
once they stop using ipecac, but this requires time and psychotherapy.

Other, and usually less serious, problems seen in bulimic patients include
damage to the teeth (caused by stomach acid in patients who vomit to purge).
Patients who make themselves vomit with their fingers may have small
lacerations and scars from old lacerations on their knuckles, caused by
scraping the knuckles with their teeth while making themselves vomit;
this is known as the Russell sign, after the adolescent medicine
specialist who first described bulimia.

Treatment of Bulimia Nervosa

Like anorexia, bulimia is often chronic. There are not yet good published
studies on how bulimic patients do in the long run; in those studies that
have been published, "good outcomes" (which are not defined the same way
in different studies) were seen in anywhere from 24% to 74% of bulimic
patients. However, since there are
therapies and medications that have been shown to be effective in
bulimic patients, this is likely to improve. The mortality (death rate)
is reportedly a bit lower for bulimic patients than for anorexic patients,
but I personally worry much more about my bulimic patients since none
of us can tell by looking at them whether they are in deep metabolic trouble.

PLEASE NOTE: As with all of this Web site, I try to give
general answers to common questions my patients and their parents ask me
in my (real) office. If you have specific questions about your
child you must ask your child's regular doctor. No doctor can give
completely accurate advice about a particular child without knowing and
examining that child. I will be happy to try and answer
general questions
about children's health, but unless your child is a regular patient of
mine I cannot give you specific advice.